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P R E S E N T E D BY :
M A R I YA M S H A K I L
•History taking of breast disease
• Breast Examination
• Recording and investigations
• Benign and malignant breast diseases
• Differential diagnosis
HISTORY TAKING OF BREAST DISEASE
• 1-Age :
• * Less than 30 years. * Older than 50 years
• 2- Residence:
• 3- Lump :
• * Duration since lump first noted * Consistency of lump presence * Change in
size * Location * Shape * Rate of growth * Associated with menses, discharge,
nipple retraction, tenderness ,dimpling and tender lymph nodes.
• 4- Pain :
• * Site ,Onset ,duration ,intermittent?* Character of pain * Associated with
menses -timing and severity * Associated symptoms -lump or any discharge
Contributing factors -trauma ,strenuous activity * Radiation – does the pain
move anywhere else? * Exacerbating / Relieving factors – does anything
the pain worse or better?
• 5- Nipple discharge :
• * Color * Unilateral or bilateral * Any associate mass
• * 6- recent nipple inversion:
• 7-eczema ,dimpling ,ulceration:
• 8-evidence of systemic disease:
• Past medical history:
• Relevant obstetric/gynecological history:
• * Age at menarche/menopause:
• * Age at first pregnancy
• * Did they breastfeed?
• * Use of hormonal replacement therapy or oral contraceptive pill
• Relevant past medical history:
• :* Recent breast trauma – fat necrosis
• * Previous breast disease – malignant or benign?
• * Any other previous malignancies?
• * Other significant medical problems?
• Surgical history:
• – breast surgery / other surgery
• Family history:
• Family history of breast disease in the family.
• A L L W O M E N O F AG E 2 0 A N D O L D E R
P E R F O R M B S E O N A M O N T H LY B A S I S
• A L L W O M E N O F AG E 2 9 TO 3 9
S H O U L D H AV E C L I N I C A L
E X A M I N AT I O N E V E R Y 0 3 Y E A R S .
• A L L W O M E N AG E S 4 0 A N D O L D E R
H AV E R E G U L A R ( E V E R Y 0 1 TO 0 2
Y E A R S ) M A M M O G R A M S .
• All examiners should normally be chaperoned
• The texture of normal breast tissue varies from smooth
to granular, also varies with menstrual cycle and
• Nodularity and tenderness often increases towards the
end of the cycle and during menstruation
• Always examine both the breast and compare the two
• The patient should be fully
undressed to the waist, with
upper body raised 45 degree
to the legs.
• Skin color
• Skin tethering
• Prominent veins and edema with
dimpling like (peau d’orange)
• Everted , flat, or inverted (recent or
• Cracking or eczema
• Gross deviation of the nipple
• Bleeding or discharge
• Areola : observe for
• Abnormal reddening
• Ask the patient to raise her arms
above her head (important for
examination of axilla and axillary
• Ask the patient to place hands on
hips and apply downward pressure.
• Inspect the breast while patient is
• Inspect the axilla , arms and
supraclavicular fossa.( Grossly
enlarged LNS/ veins/ edema) may
• Healthy women may have some
• Patient lies on the the couch , lying flat with pillow
behind the head.
• Arms by her side or behind her head.
• Palpate with the flat of the finger using middle
• Either begin with the normal side or feel both the
• Get on level with the patient.
• Use rotatory motion to gently press the breast
tissue against the chest wall.
• Palpate the axillary tail which lies on the anterior
• LUMP : site , size, shape, surface ,edge, and
consistency. Bi-manual examination controlling
movement of the lump with one hand and feeling
with the other.
• Examine the breast systematically , covering the whole
cone of the breast tissue using one of the following 03
• 1. zigzag 2. concentric. 3.cricular
• A systemic methodological exam, covering all four
quadrants, axillary tail, areola and nipple.
• With large breast use one hand to steady the breast.
SYSTEM OF THE BREAST PALPATION
• The examiner zigzags up
• Preferred method for self
• Advantage: Breast tissue
remains in contact with the
chest wall during palpation.
SYSTEMS OF THE BREAST
PALAPATION 2/ CIRCULAR
• Breast tissue is examined
using a circular approach
• The examiner starts at
periphery and ends at the
areola and nipple.
SYSTEMS OF THE BREAST
• The examiner divides the
breast in series of
• The quadrants are
from periphery towards
• The examiner traces a
pattern similar to a clock.
• To examine the axillary
tail, ask the patient to
rest her arms above her
• Feel the tail between
thumb and fingers(
extends from the upper
outer quadrant towards
NIPPLE AND AREOLA:
• To examine the nipple; hold
the areola between thumb
• Gently compress, attempting
to express discharge.
• Note color of any discharge,
send for cytology.
• Cover the patient .
EXAMINATION OF AXILLA:
• Stand on the patients right side.
• Patients arm is raised and supported.
• Take hold of right elbow with your right hand
and let her forearm rest on your right
• Place your left hand flat against the chest wall
and feel for any glands by sweeping tips of
your fingers to catch the glands against the
• Slightly cupped hands are then inserted into
the apex of the axilla ( push firmly).
• To examine the left axilla, move around to the
left axilla hold her left elbow with your left
hand and use your right hand to feel the
• Palpate the clavicular fossa and the neck.
• Note No, size and consistence of any glands
• Check the arms for swelling or any
• Palpate the abdomen, look for hepatomegaly/ascites.
• Examine the lumber spine for pain or restricted
RECORDING AND INVESTIGATIONS:
• Identify which quadrant and which breast. (Right upper outer
• Best to record graphically.
• TRIPLE ASSESMENT:
• women with suspected cancer receive triple assessment,
which consists of
• 1. HISTORY AND EXAMINATION
• 2. MAMMOGRAPHY/ ULTRASOUND SCAN.
• 3. CYTOLOGY(FNA) OR HISTOLOGY(BIOPSY).
–SIMPLE NIPPLE INVERSION:
• Retraction occurring during puberty
• Of unknown etiology.
• May cause infection during breast feeding.
• RECENT RETRACTION OF THE NIPPLE: Is of considerable
• SLIT LIKE RETRACTION: may be caused by ductal ectasia
and chronic pre ductal mastitis.
• CIRCUMFERENTIAL RETRACTION: with or without lump
• CRACKED NIPPLE: May occur during lactation. It should be rested for 24-48 hrs.
• PAPILLOMA OF THE NIPPLE: should be excised with a tiny disc of skin or the base
maybe tied to a ligature and the papilloma will fall off.
• RETENTION CYST OF GLAND OF MONTGOMERY: These glands, situated in the areola,
• If blocked can cause sebaceous cysts.
• ECZEMA: Rare, often bilateral. Treated with 0.5 per cent hydrocortisone.
• PAGETS’S DISEASE: Occurs due to malignant
cells in in the subdermal layer.
• Usually associated with carcinoma.
• Should be differentiated from eczema.
• Nipple is eroded slowly and eventually disap-
DISCHARGE FROM THE NIPPLE:
• DISCHARGE FROM THE
• Paget’s disease
• Eczema, psoriasis
• Discharge from a single duct:
• Intraduct pailoma
• Intraduct carcinoma
• Fibrocystic disease
• Duct ectasia
• DISCHARGE FROM MORE THAN
BLOOD STAINED: CARCINOMA
BLACK OR GREEN: DUCT ECTESIA
SEROUS: FIBROCYSTIC DISEASE
CONGENITAL DISEASES OF THE
•Amazia: congenital absence of the breast.
• It is associated with absence of the sternal potion of the
pectoralis major(POLAND’S SYNDROME)
• More common in males.
•POLYMAZIA: Accessory breasts
•Most commonly occur in axilla, groin
• MASTITIS OF INFANTS: Milky secretion on the 3rd
or 4th day of life, if the breast is slightly pressed
• It is physiological.
• Caused by stimulation of fetal breast
by prolactin due to drop in maternal
• TRUE MASTITIS: Relatively uncommon
caused by staph aureus.
•The breast attain enormous dimensions.
•In early puberty or 1st trimester of pregnancy.
•Due to the alteration of the normal sensitivity of
the breast to oestrogen.
•Treatment: Anti-oestrogens or reduction
INJURIES OF THE
• H E M ATO M A : G I V E S R I S E TO A L U M P
• T R A U M AT I C FAT N E C R O S I S : M AY B E A C U T E O R
C H R O N I C , U S U A L LY O C C U R S I N S TO U T M I D D L E A G E D
W O M E N .
• F O L LO W I N G A B L O W.
• P R E S E N T S A S A PA I N L E S S L U M P.
• M AY M I M I C A C A R C I N O M A .
• D X : B I O P S Y ( H I S TO R Y O F T R A U M A I S N OT
D I A G N O S T I C )
ACUTE AND SUBACUTE
INFLAMMATION OF THE BREAST
• BACTERIAL MASTITIS: Most common variety
• Associated with lactation.
• Caused by S.aurues (mostly staphylococcus
present in the infants nasopharynx)
• PRESENTATION: Classical signs of acute inflam-
• Early on presents as cellulitis later an abscess
1. Antibiotics (flucloxacillin/ co-amoxiclav)
• Local heat and Analgesia for pain.
• Infection not resolved for 48 hrs. : Incisi-
on and drainage.
• Or repeated incision using antibiotic
• TUBERCULOSIS OF THE BREAST:
• Associated with active pulmonary TB
or TB cervical adenitis.
• PRESENTATION: Multiple chronic sinuses
• Bluish appearance of the surrounding skin.
• DX: Bacteriological and histological examin-
• TREATMENT: Anti- TB chemotherapy.
• Mastectomy in persistent cases.
M O N DO R’S
D I S EAS EOF T H E
B R EA S T
Thrombophlebitis of the
superficial veins of the chest
and ant. Chest wall.
In the absence of injury
cause is unknown.
vein .attached to the skin.
When the arms are raised, a
shallow groove appears.
DUCT ECTASIA/PERI DUCTAL MASTITIS:
• It’s a dilation of the breast ducts.
• Often associated with peri-ductal inflammation.
• COMMON IN SMOKERS( increases the virulence of commensal bacteria).
• PATHOGENESIS; Disorder of dilation in one or more lactiferous ducts.
• Which fill with brown or green secretions>discharge> irritation> periductal
• CLINICAL FEATURES:
• Sub areolar mass.
• Nipple discharge.
• Fistula of mammary duct.
• Nipple retraction(slit like) due to fibrosis.
• TREATMENT: In case of nipple retraction and mass carcinoma must be
• Antibiotic therapy.
• SURGERY: HADFIELD’S OPERATION( EXCISION OF ALL THE MAJOR DUCTS).
BREASTB R E A S T C A N C E R I S O N E O F T H E L E A D I N G
C A U S E O F D E AT H I N M I D D L E A G E D W O M E N
I N W E S T E R N C O U N T R I E S . T H E I N C I D E N C E I S
T H O U G H T TO C O N T I N U E R I S I N G A LT H O U G H
M O R E S L O W LY T H A N P R E V I O U S LY D U E TO
R E D U C E D U S E O F H R T D R U G S .
• 1.GEOGRAPHICAL ( mostly occurs in western countries 3-5% death in all
• 2. AGE( extremely rare before age of 20,incidence rises so that at 90yrs
almost 20% are effected)
• 3.GENDER (< 0.5% are male)
• 4. GENETIC( occurs most commonly with family history)
• 5. DIET( alcohol consumption and links with diet low in phyto-oestrogens.
• 6.ENDOCRINE ( most commonly in nulliparous women, post menopausal
obese women, long term use of combined preparation of HRT); ( breast
feeding and having first child at an early age is thought to be protective).
• 7.PREVIOUS RADIATION ( Women who have been treated with mantle
radiotherapy in Hodgkin’s disease, risk appears after a decade of
Breast cancer may arise from the duct system anywhere from the
nipple end of the major lactiferous ducts to the terminal duct unit
, which is the breast lobule.
Disease maybe entirely in situ.
Degree of differentiation: 03 grades ( well differentiated,
moderately differentiated or poorly differentiated)
Commonly, numerical grading system : Based on 3 factors is used
1. Nuclear pleo-morphism
3. Mitotic rate
With grade 3 equating to poorly differentiated group.
On the basis of gene analysis 05 types have been identified.
INVESTIGATION OF BREAST LUMP
USING FINE NEEDLE CYTOLOGY
• CYSTIC : Lump disappears ,clear fluid Discharge patient
Residual thickening, blood stained fluid. Investigate/core biopsy
• SOLID : Benign Offer excision or observe
Atypical Investigate/ core biopsy
Malignant Treat for cancer.
NOMENCLATURE OF BREAST
• 1.DUCTAL CARCINOMA ( most common variant, DCIS classified using Van Nuys
classification, combines age, type, presence of micro calcifications, extent and size of
• 2. LOBULAR CARCINOMA( 15% of cases , E-cadherin antibody positive, on immuno-
histochemical assay, multifocal and bi-lateral, MRI for assessment)
• 4.COLLOID OR MUCINOUS CARCINOMA(rare, better prognosis, contains abundant
• 5.MEDULLARY CARCINOMA(solid sheets of cells, marked lymphocytic reaction,
• 6.INFLAMMATORY CARCINOMA( rare, highly aggressive, presents as painful, swollen
breast ,warm with edema, mimics an abscess
SPREAD OF BREAST CANCER:
• LOCAL SPREAD: ( Tends to involve the pectoral muscle and chest
wall if dx late)
• LYMPHATIC SPREAD: ( To Axillary and Internal mammary nodes,
involvement of contralateral and supra clavicular nodes represents
• SPREAD BY THE BLOOD STREAM( via this route skeletal metastasis
• Order of frequency ; 1. Lumber vertebrae 2.Femur 3. Thoracic
vertebrae 4.Ribs and Skull.
• Metastasis also commonly occurs in the liver, lungs and brain.
• Breast cancer is most frequently found in upper outer
• Mostly present as hard lump, with in drawing of nipple.
• Skin maybe involved with peau d’orange appearnce.
• Cancer may involve the chest wall and known as cancer-en-
• STAGING: by means of TNM( tumor node metastasis) OR UICC
UICC (Union contre le cancer)
• Staging evaluation Includes: careful clinical examination , chest
X ray, CT of the chest and abdomen and isotope bone scan.
TREATMENT OF CANCER OF THE
• Two basic principles: 1. To reduce local recurrence 2. To reduce risk of
• Early breast cancer: surgery with or without Radiotherapy(local
• Systemic therapy i.e. Radiotherapy and chemotherapy is added when
worse prognostic factors present such LN involvement.
• Chemotherapy include Herceptin if Her-2 positive.
• Hormone therapy: if oestrogen receptor or progesterone receptor
• It’s a Multidisciplinary team approach: Good-patient communication
• Plays a central role.
• Trials have shown equal efficacy between mastectomy and local excision.
• Mastectomy: indicated for large tumours, central tumours beneath or involving the
nipple, multifocal disease, local recurrence.
• MODIFIED PATEY MASTECTOMY: More commonly used.
• The breast and associated structures are dissected en bloc.
• The excised mass is composed of:
• The whole breast
• Large portion of skin, always includes the nipple.
• All of the fat, fascia and LNS of the axilla.
• Pectoralis muscle is either retracted or divided to gain access to the axilla.
• The veins and nerves to the serratus anterior and litissimus dorsi are preserved.
• The wound is drained using wide bore suction tube.
• Early mobilization and physiotherapy is encouraged.
CONSERVATIVE BREAST CANCER
SURGERY:• Removes the tumour plus a rim of at least 1cm of breast tissue.
• Commonly referred to as wide local excision.
• Lumpectomy is used for benign tumours excision.
• Quadrectomy: includes removing entire segment of breast containing the
• Both of these surgeries include AXILLARY SURGERY via separate incision.
• SENTINAL NODE BIOPSY: Standard in management of the patient in node
• Axillary surgery is done to stage the patient, presence of metastatic
disease in axillary nodes is the best marker for prognosis.
• Higher rate of recurrence even combined with radiotherapy.
• In higher risk patients radiotherapy to the chest wall after mastectomy is indicated.
• Includes large tumours, high risk of recurrence, large no. of positive nodes,or extensive
• Local excision is combined with radiotherapy as excision alone has very high recurrence
• ADJUVANT SYSTEMIC THERAPY:
• Outcome of the treatment depends on the extent of MICROMETASTATIC DISEASE.
• Systemic therapy targeting these micro-metastasis delays relapse and prolong survival.
• Adjuvant chemo or radiotherapy will improve relapse free survival rate by 30%.
• HORMONE THERAPY:
• Tamoxifen most widely used.
• Reduce annual recurrence by 25%.
• Others agents includes ;LHRH agonists induce reversible ovarian suppression.
• AIs (oral aromatase inhibitors) for post-menopausal women.
• Using first generation regimen such as;
• Six monthly cycle of cyclophosphamide, methotrexate
• Reduce 25% reduction in relapse for 10-15 years.
• Anthracycline(doxorubicin) over CMF considered in newer
• Follow up:
follow up for life
yearly or two yearly mammography recommended.
• PEAU D’ORANGE:
• Resulting from lymphatic obstruction
in advanced breast cancers.
• Cause by cutaneous lymphatic
• Appears as purple or red color of the
skin with pitting or thickening of skin,
resembling an orange peel.
• Late edema of the arm is troublesome
complication of breast cancer
• Due to lymphatic and venous
• Limb elevation, elastic arm stockings
and pneumatic compression devices
• Breast reconstruction can be
offered immediately after
• Silicone gel implant under the
pectoralis major muscle.
• Musculocutaneous flap can be
constructed using latissimus dorsi
(LD flap) or tranversus abdominis
muscle (TRAM FLAP).
• Screening: by mammography in
women over 50 yrs is
CARCINOMA OF THE MALE BREAST:
• Less than 0.5% cases.
• Predisposing causes :
and exogenous steroids.
• Presents as as LUMP.
• Mostly commonly as infiltrating
• Treatment : local excision with